| NPI | 1124704895 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OR 10045770) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: AZ 294125) |
| Enumeration Date | 2023-06-26 |
| Last Update Date | 2025-10-13 |